Depersonalization PTSD Questionnaire

Use the Depersonalization PTSD Questionnaire to evaluate the severity of their trauma and depersonalization symptoms based on their presence, frequency, and duration. 


By Patricia Buenaventura on Jun 20, 2024.

Fact Checked by Nate Lacson.

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Depersonalization PTSD Questionnaire PDF Example
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What is Trauma and PTSD?

Trauma pertains to experiences that profoundly affect individuals, rendering them incapable of effectively coping. Such events include natural disasters, abuse, violence, accidents, and witnessing such occurrences.

Experiencing or witnessing trauma can lead to the onset of Post-Traumatic Stress Disorder (PTSD), Signs and symptoms of PTSD include nightmares, intrusive thoughts, avoidance of situations related to the trauma, heightened alertness, and adverse changes in thinking and mood.

The causes of PTSD can vary among individuals, even if they�??ve undergone the same traumatic event. Genetic predisposition, imbalances in brain chemistry, previous exposure to trauma, and a lack of social support can all contribute to the development of PTSD.

The typical treatment of PTSD often combines medication with therapeutic approaches such as Cognitive-Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). These interventions are meant to manage symptoms, facilitate the processing of traumatic experiences, and foster the development of adaptive coping strategies.

Printable Depersonalization PTSD Questionnaire

Download this Depersonalization PTSD Questionnaire to assist clients in assessing the severity of their trauma and depersonalization symptoms.

How to use the Depersonalization PTSD Questionnaire:

Step One. Access and Download the Template 

Access and download a digital and printable copy of the �??Depersonalization PTSD Questionnaire by doing either of the following:

  • Clicking the �??Use Template�?� or �??Download Template�?� button
  • Searching �??Depersonalization PTSD Questionnaire�?� in Carepatron�??s template library�??s search bar on the app or website

Step Two. Answer the Questionnaire 

If your client has experienced trauma and is exhibiting symptoms of depersonalization or you suspect depersonalizes to cope, have them answer the questionnaire independently. If they are unable to do it themselves, you may read the questions to them out loud and have them answer verbally. 

Step Three. Interpret the Scores 

After answering the questions, interpret the scores with the scoring explanation provided below or in the template provided. You may use the interpretations obtained when formulating your client's next steps. 

Step Four. Securely Store the Template

Don�??t forget to store the template at the end of your session securely. Place them with the clients�?? other records in your secure physical storage or on Carepatron, a HIPAA-compliant EHR with a patient portal. 

How do you score the Depersonalization PTSD Questionnaire?

Before interpreting, you must first obtain a score. Although we�??ve provided instructions on the template, for good measure, here is the exact step-by-step guide on how to score the Depersonalization PTSD Questionnaire you will find:

For part 1, If they answer yes on certain statements, give them the corresponding points for each answer:

  • For statements 2, 3, 6, 10, 13, 16, 22, 25, 26, and 28, give each answer 10 points;
  • For statements 1, 4, 5, 7, 9, 11, 14, 15, 29, and 30, give each answer 20 points and
  • For 8, 12, 17, 18, 19, 20, 21, 23, 24, and 27, give each answer 30 points.

For part 2, add all of the frequency and duration markings.

Depersonalization PTSD Questionnaire Example

Here�??s a printable and digitally accessible PDF file of a completed �??Depersonalization PTSD Questionnaire�?� template. You may use the guide, reference, educational resource, and visual aid when explaining how to do the worksheet to your client. However, do not forget that the answers in the sample worksheet are fictional. 

Obtain a copy by viewing the example below or clicking the �??Download Example PDF�?� button. 

Download this Depersonalization PTSD Questionnaire Example:

Depersonalization PTSD Questionnaire Example

When would you use this Depersonalization PTSD Questionnaire?

The Depersonalization PTSD Questionnaire is usually used by mental health practitioners, such as psychologists and psychiatrists, to check the severity of the client�??s trauma and the presence and severity of their depersonalization symptoms. They can use it in specific situations like: 


The referring physician can use the questionnaire to understand their client�??s condition while the client can use it to understand themselves better and be more aware of their symptoms over time. 

Diagnosis and Treatment Planning

The questionnaire can be one of the many tests one can use to diagnose the client's possible mental condition. Then, the referring physician may ask the client to retake the test to evaluate a therapeutic approach's effectiveness. 

Research Studies

Researchers can use the questionnaire to identify the prevalence of depersonalization and the characteristics of it in specific groups of people to understand the condition better and formulate a more effective treatment. 

What are the benefits of using this Depersonalization PTSD Questionnaire?


One must be self-aware to assess the presence, frequency, and duration of one�??s depersonalization symptoms. Then, after the test, to effectively apply the coping strategies provided by the referring physician, they must learn to be self-aware of when they may experience or are experiencing their symptoms.

Monitor the Severity of Symptoms

The referring physician can use the test to measure the severity of their symptoms and monitor it over time since the client can be asked to answer the questionnaire as often as needed. 

Compare the Outcome of Treatments

When a referring physician recommends a treatment approach, they can use the questionnaire to assess if the treatment is effective by comparing the answers before and after it. 

Digitally Accessible

Our free �??Depersonalization PTSD Questionnaire�?� is digitally accessible. When needed, the referring physician can have their client answer it on a PDF editor or the Carepatron app on any gadget they have on hand. Furthermore, if you store it on Carepatron, relevant parties can also access the questionnaire on any gadget with the downloaded software. 

Why use Carepatron as your Cognitive Behavioral Therapy app?

Carepatron, a practice management software, has been helping licensed and experienced psychologists, psychiatrists, counselors, and therapists who conduct CBT therapy sessions more effectively manage their practice. And if they can raise the caliber of their practice with Carepatron, you can, too!

On a single platform, Carepatron, you can use the available features and tools to automate tasks and streamline processes related to:

Clinical Documentation

Instead of starting from scratch, save time and effort by using, customizing, completing, and storing over 1,000 templates of notes, invoices, and medical documents.

Medical Scheduling

Allow your clients to request appointments independently for your approval. Then, reduce approved upcoming appointments by setting up a system that can send your clients automated reminders via SMS or email.

Medical Billing

With Carepatron, you can offer alternative payment options, send automated reminders of payment dues, and process your clients�?? payments quickly.

Patient Records

Using our patient portal, inputting and searching for patient details in records are easy and effortless.

Need some help in being more productive or raising the caliber of your practice? Explore how Carepatron can assist you with your needs today. Sign up for free access and an account!

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How long does it normally take to accomplish the Depersonalization PTSD Questionnaire?
How long does it normally take to accomplish the Depersonalization PTSD Questionnaire?

Commonly asked questions

How long does it normally take to accomplish the Depersonalization PTSD Questionnaire?

It can take around an hour to answer, score, and interpret the results of the Depersonalization PTSD Questionnaire. 

How can the Depersonalization PTSD Questionnaire help people?

It can help clients be more aware of the depersonalization symptoms. On the other hand, it can also help the referring physician assess the severity of the patient�??s depersonalization symptoms for diagnostic or treatment formulation purposes. 

When is this Depersonalization PTSD Questionnaire best used?

It�??s best used when the referring physician suspects or is aware that the client is experiencing depersonalization symptoms after a traumatic event and when monitoring the effectiveness of a particular treatment approach.

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